The problem is not how to decrease specialty pharmacy cost; that will never happen. Rather, it is how to reduce the rate of increase in specialty pharmacy cost. Payers face a market characterized by a growing number of specialty drugs with high price tags. Specifically, Express Scripts’ Drug Trend Report predicts that hepatitis C drug spending will quadruple from 2013 to 2015 — just two years — the greatest percentage increase of all therapeutic areas. Gilead’s Sovaldi is the most recent drug approved for hepatitis C and is, rest assured, the first of several pipeline hepatitis C drugs from AbbVie, Bristol-Myers Squibb, and Achillion that will contribute to this upward trend. Let’s take a closer look at Sovaldi from the formulary decision-maker perspective.
Formulary decision-maker concern
How these concerns can be addressed
Sovaldi costs about $84,000 per 12-week course. This may be unsustainable.
Although the drug cost may be high, it might be offset by avoiding side effects and hospitalizations that may be associated with cheaper competitors. Gilead made such a case at the 2013 International Liver Conference, presenting data on real-world costs of competitors. This is especially relevant inasmuch as hepatitis C is the leading cause of liver transplants. Furthermore, consider oncology drugs whose prices may be just as high but often do not have cure rates as high as Sovaldi’s.
Payers may feel compelled to provide unrestricted access to Sovaldi because of its potential to increase adherence because it is a once-daily oral drug that avoids the side effects associated with other drugs.
Sovaldi’s cheaper competitors may be perceived as an obstacle to adherence because of their safety profiles and the fact that they are injectables. Adherence may be boosted by effective specialty pharmacy programs.
Diagnoses of hepatitis C will increase because of new screening guidelines. Therefore, the total cost of treating hepatitis C will increase.
Newer diagnostic tools that are also less invasive, such as FibroScan, may allow payers to tightly manage access to Sovaldi by requiring routine screening before coverage is approved.
Gilead has refused the Fair Pricing Coalition’s demand for lower pricing of Sovaldi, although it has agreed to yield to the FPC’s requests regarding Sovaldi access programs, such as SupportPath, which help patients in need of financial assistance.
Express Scripts, one of the largest PBMs, threatens to block Sovaldi from coverage altogether if its pipeline competitors will accept lower pricing.
Cost increase of hepatitis C treatment will far exceed specialty drugs in general
Sources: HCV Research and News, GlobalData, CVS Caremark Insights, AIS, Bloomberg, Express Scripts